Category: Policy and politics

Saying no to CT

published date
November 2nd, 2006 by

Saying no to CT

Advanced CT scanners have revolutionized trauma care and provided physicians with lots of information to aid diagnosis and track treatment progress. Utilization has gone through the roof, which is good news for radiologists and hospitals but bad news for payers. There has been no significant progress in holding the line on imaging costs, the way there has been on drugs, for example.

But there is growing concern over the high dosage of radiation that some patients receive from CT scans, according to the Wall Street Journal. A chest CT exposes the patient to 8-10 millisieverts of ionizing radiation. That’Â’s 100 to 1000 times as much as a chest x-ray, and about half of the exposure received by the average atomic bomb survivor in Hiroshima or Nagasaki. Some patients get dozens or even hundreds of scans. No doubt not all those scans are necessary.

I’ve always been leery about medical radiation exposure. My mother was conservative about letting us have our teeth x-rayed, and she was probably right. If payers want to rein in CT costs, they’d be wise to tap patient safety concerns. However, if they aren’t careful they will just drive up the use of MRI, which costs even more.

Boston Globe sides with the sippers

published date
October 31st, 2006 by

Boston Globe sides with the sippers

I’m voting “No” on Massachusetts ballot question 1, which would permit the sale of wine in more food stores, because I think it would increase underage drinking and associated problems. Unfortunately, the Boston Globe sees things differently and has advocated a “Yes” vote:

[T]he availability of wine with groceries does make life a little more convenient for the many adults who like to sip wine with their dinner…

Ok, as long as it’s just sipping wine then I guess it’s ok. But I’m more worried about the chuggers and those who skip dinner entirely!

I’m voting “No” on Massachusetts ballot Question 1

published date
October 27th, 2006 by

I’m voting “No” on Massachusetts ballot Question 1

In Massachusetts, alcohol is sold at liquor stores (called “package stores” here) and at a limited number of grocery stores. Most other states have more liberal rules than we do about where alcohol can be sold. It’s the norm in the US to have alcohol sales in supermarkets.

Question 1 on the Massachusetts ballot asks voters whether to expand the number of licenses that can be issued to grocery stores to sell wine. Predictably, grocery stores support the measure while package stores oppose it. There’s nothing principled about their arguments, but that doesn’t mean that there isn’t merit to some of what they say.

Supporters, led by Grocery Stores and Consumers for Fair Competition argue that a Yes vote will reduce prices and provide consumers with more choice. They cite the experience of other states.

Opponents, led by Wine Merchants and Concerned Citizens SAFETY (Stopping Alcohol’s Further Expansion to Youth) argue that a Yes would make it easier for kids to buy alcohol, which would increase the number of alcohol related problems such as drunk driving fatalities. This is especially likely because there is no provision to increase resources for enforcement of minimum age laws.

I agree with the wine merchants more than the grocers. I don’t believe that Massachusetts will do a good job of keeping grocery stores from selling to underage buyers. I don’t doubt that the owners of the stores will try to avoid selling to kids, but when a large part of the checkout staff are themselves underage I think it will be hard to stop.

A better idea might be to hold the package stores to a higher standard, putting them at greater risk of license forfeiture for underage selling.

Another dirty little secret is out in the open

published date
October 25th, 2006 by

Another dirty little secret is out in the open

A year ago in Time to deal with medicine’s dirty little secrets?, I wrote about a variety of practices that are relatively well-known in the health care field but would be shocking to outsiders. Industry often takes the blame for “aggressive marketing tactics,” and no doubt some of that is deserved. But physicians are also culpable.

The open secrets include the ghostwriting of journal articles by industry sponsors, physicians and academic medical centers holding ownership stakes in companies whose products they are researching, the clinical role sometimes played by orthopedic sales reps, and perhaps the most egregious example: physicians who set guidelines having financial relationships with the companies that benefit from how those guidelines are set.

Now we have a new example, which is even more serious than usual. A recent New England Journal of Medicine article blames Eli Lilly for overzealous promotion of Xigris. According to the Boston Globe:

Eli Lilly and Co. funded medical guidelines created for the treatment of [sepsis] in an effort to boost sales of a drug with questionable benefits. The allegation was made by senior scientists at the National Institutes of Health. [They] said Lilly tried to shape the guidelines for use of the drug Xigris by sponsoring a three-pronged marketing campaign

The first two phases are by now almost standard practice in the industry:

  1. Lilly paid a task force to spread the word that hospitals were rationing Xigris because of its cost, which forced docs “to decide who would live and who would die”
  2. Lilly “orchestrated” the development of practice guidelines to treat sepsis that called for early use of Xigris (an example of the phenomenon I have described before)

But then Lilly allegedly took a third step, which was a little shocking even to me:

Now, Lilly is sponsoring lobbying efforts to turn the guidelines into quality standards. Hospitals that follow such quality measures receive higher payment from insurers.

What’s happening here? Basically, an influential group of doctors is being lazy and greedy, and Lilly is enabling their behavior. The doctors put their fingers in the cookie jar and Lilly keeps restocking it. The public is paying for the cookies –in the form of higher product sales and sub-optimal health care– and should get fed up!

I have no problem with companies using legal means to promote their products, even if their tactics are “aggressive.” They owe it to their shareholders to maximize return on investment. But it isn’t in their long-term interest to push things as far as the medical profession often lets them.

Industry leans on the reputations of individual physicians (aka “key opinion leaders”), medical societies (aka guideline writers), and journals to legitimize their marketing messages. It’s up to the medical profession to scrutinize industry claims and issue independent guidelines and quality standards. Sometimes these claims hold up and deserve to be propagated. Sometimes they don’t. If the docs and journals don’t do their jobs they deserve to lose credibility.

It’s hard to know the extent to which medical guidelines are already corrupted. The situation is a bit like the incident when the Chinese President’s plane was refitted. In the process of fixing up the plane someone inserted a bunch of listening devices (presumably at no extra charge). When the Chinese checked out the plane and realized it was bugged they had to rip the whole thing up. That’s something like what is going on within the major payers. They’ve stopped treating journal articles and guidelines as objective and have started doing their own analyses. But do we really want to leave health care decisions just to them?

Here’s some free advice to the different players in health care:

  • Industry: Feel free to market your products and services aggressively, but don’t take things too far. If you do you’ll end up killing the goose that lays the golden eggs. No one will trust doctors, guidelines or journals anymore
  • Physicians: Remember that pharma and device companies are not stupid. If they spend money supporting your research or sending you to conferences or sponsoring continuing medical education it’s because they expect to get a return on their investment. It’s awfully hard to remain objective in such instances. Your job is to adopt the best medical practices and put the patient first –sometimes that requires expensive new treatments and sometimes old, cheap standbys are better
  • Payers: Go ahead and challenge the objectivity of journal articles and guidelines. On the other hand, don’t pretend that low cost is always synonymous with best treatment. Expect physicians to keep you in line on that.
  • Patients: You need to look out for yourself. Find a good, honest physician. Take a look at who’s sponsoring the educational materials you receive. Ask your physician about alternative treatments and do some research yourself

A head lice policy that isn’t a nuisance

published date
October 20th, 2006 by

A head lice policy that isn’t a nuisance

As I’ve written before (George Bush: Louse Enabler?), schools tend to go overboard on their head lice policies, enforcing strict “no nit” rules that don’t make a lot of sense. So I was happy when I found the following announcement from a local school. It seems like a very sane way to go:

We realize that some parents are quite concerned about head lice, and wanted to provide some useful information to inform you about what we are experiencing and to reassure you about how we manage the problem as an institution. [Note: a recent newsletter article gave parents practical tips on lice management at home.]

Why are there so many cases of lice this year?

We had heard reports that summer camps were over-run with cases of lice this summer, so we anticipated that we might experience more problems than usual at the start of the school year. That is why we reminded parents about checking heads carefully before school began (in the August packet) and why we remind parents to continue to do so every week in the newsletter.

To put things in perspective, we have experienced less than ten cases of lice in the entire school so far this year.

Why don’t we do school-wide head checks like some other schools do?

Experience has taught us that conducting school-wide head checks is not only disruptive to teachers and students and very time-consuming, but also that it rarely yields any cases of lice. At home, parents can do a much more thorough exam of their own children on a regular basis. That is why we ask you to take that responsibility.

Neither the American Academy of Pediatrics nor the National Association of School Nurses is in favor of group screenings. Both research and anecdotal reports have indicated that the excessive amount of time it takes to conduct group screenings is not productive.

Why does our school have a “modified no-nit policy”?

We modified our policy several years ago to keep in line with the most recent research concerning head lice management, and we follow recommendations from the American Academy of Pediatrics and the National Association of School Nurses.

According to Richard J. Pollack, PhD, of Harvard School of Public Health, “No child should lose even an hour of school because of head lice. By the time you find head lice, that child has likely been infested for a month or more.” Therefore, we have chosen to have a different policy than the policies still in place in some other schools and school systems. Our policy reflects good, current clinical practice. We have an excellent, ongoing relationship with the local Department of Public Health, our nursing and medical liaisons there are fully supportive of how we handle head lice.

Here is what our experience has been:

  • In the several years since we modified our policy, we have actually experienced a decrease in the numbers of children who develop head lice after cases are diagnosed and appropriate management begun.
  • Most cases of head lice in our school have been discovered by parents when the child is at home. This year, only one of the cases of head lice was diagnosed by the nurses while the child was in school, and that child’s parents chose to take the child home early.
  • In every instance where the nurses have checked children’s heads in a classroom because a case of lice has been reported, no other cases have been detected from that check. That is a common reported experience from schools across the country. It bolsters the fact that head lice are less communicable than people realize. Remember, lice cannot jump or fly: they are communicated by very close contact with somebody who has the problem.

Therefore, educating students about measures to avoid the problem, such as wearing hair tied back, not sharing hats or other hair implements, and not putting heads together, is a much more effective tool than excluding children from the classroom. We also take institutional measures, such as careful vacuuming, putting away dress-up clothes, etc, when indicated. We suggest that parents reconsider having sleepovers when there are reported cases of lice in their childՉ۪s grade.

  • Once a child is diagnosed with head lice, we work closely with parents to help manage the case effectively. We check affected children when indicated and check in with parents to see if they need further advice and support. Since having head lice in the family is never a pleasant experience, we know that parents whose children have lice do everything in their power (following our instructions and those of their pediatricians) to take care of the problem.

We hope that this information helps parents to put the lice situation in perspective.